Susan (pictured on the right) is a Nurse Navigator with Seniors Home Support (SHS), an integrated program between Oak Valley Health and community partners that delivers seamless primary care to home-bound seniors.

“In my job, because I’m hospital-based but community-facing, I can appreciate how difficult it is to work in both settings,” she says.

Susan previously worked in community care, where she guided individuals through decisions about home care versus hospitalization and assisted people in planning their care goals as their health declined. “When they went into the hospital, it’s like they went into a black vacuum,” she says. “I wouldn’t know what happened to them because I wasn’t in their circle of care.”

After transitioning to work in the hospital environment, Susan encountered a new set of challenges. “When you’re a hospital provider, you actually have no idea where people are being discharged to. It’s just not within your radar.”

Having experienced both sides now, Susan is happy that in her current role, she’s able to serve as a vital connector between hospital and community care.

Critical connections

Establishing and maintaining strong connections with our community partners is a priority for Oak Valley Health and helps us provide both integrated care and an extraordinary patient experience.

Susan’s recent encounter with William Swartz, whose wife Francine is a client of SHS, illustrates just how vital this integration is.

Francine is bedbound and, along with the loving, attentive care of her husband, is fully dependent on a gastrostomy tube to receive nutrition and medication.

As Susan recounts, in her previous interactions with William, she had what she describes as “nice phone conversations.” This typically involved checking in on Francine and occasionally liaising with the couple’s family doctor because “we really work closely as a team.” Rarely did William reach out to Susan for anything more.

That was until, one day, William called up Susan and told her that Francine had a problem with a broken gastrostomy tube.

“He said, ‘I need this connector piece,’” explains Susan. “And I didn’t know what to do.” Susan asked William to take a photo of the broken part and send it to her. “I didn’t know what I was looking at, but I’m so lucky to be embedded within a network where I can reach out.”

Through her hospital connections, Susan obtained an interventional radiology consult through Carolina Rotella, a Diagnostic Imaging Navigator, and was able to receive a replacement part within the hour.

One of the questions that arose was how they were going to get the part to William, since a timely solution was critical. “In my mind, I was like, that is the smallest issue,” says Susan. “I will drive it to his house so don’t worry. That’s such a small thing.”

It turned out that William was able to meet Susan at the hospital to pick up the connector, though not before ensuring that Francine was taken care of while he was away, since she couldn’t be left alone.

When Susan met him in the lobby, a grateful William paused and said to her, “Susan, you have no idea what this means. This will save Francine.”

What she later learned was that it wasn’t the first time the couple had been through the same scenario.

“I went through this once before,” William later explained. “The problem was that a little piece of the plastic broke, so I called 911 to bring Francine to the hospital because she is immobile. It required paramedic and firetruck response to take Francine to the Emergency Department. There was no direct cost to me, but this is an expensive response for York Region and the hospital.”

While the procedure to change the connector took just five minutes, the couple waited two hours and after it was done, had to wait three more hours for private transport to bring Francine home. There was no OHIP coverage or provision to take Francine home in that situation because it was deemed as non-medical. Nor was the expense covered by the couple’s private insurance.

This time, however, William was able to bring the part home and, with the assistance of a homecare nurse, make the repair on their own, avoiding the disruption and stress of having to bring Francine back to the hospital.

In the end, this story is about a small connector that demonstrates the power of connections, an example of how something so little can make a big difference. And, for Susan, it’s one of the reasons she finds her work so rewarding.

“I flat out feel I have the best job,” she says. “I hope I never lose that feeling.”